<div class="clinical-article"> <div class="heading"><img src="/publishingimages/new_tocs/clinical_points.gif" alt="clinical points" /></div> <p class="take-home-head-clin-pts"></p> <ul> <li class="clinical-points">Auditory hallucinations are common neuropsychiatric symptoms in DLB, and the majority of patients with auditory hallucinations also had visual hallucinations.</li> <li class="clinical-points">Auditory hallucinations consist mostly of human voices and usually appear as a background soundtrack accompanying their visual hallucinations.</li> <li class="clinical-points">Auditory hallucinations in patients with DLB are more likely to occur in women and those with impaired hearing, depression, delusions, or visual hallucinations.</li> </ul></div>

<p class="subheads-subhead-2">Assessment of Demographic Variables and Neuropsychiatric Symptoms</p> <p class="body-text">We collected patients’ demographic information, including previous disease and drug history, through clinical interviews with their caregivers. Hearing impairment was defined as “present” if the patient had difficulty hearing to an extent that interfered with daily living.</p> <p class="body-text">We assessed the patients’ comprehensive neuropsychiatric symptoms, including auditory hallucinations, through a semiquantitative interview with their primary caregivers using a Japanese version of the NPI.<span class="htm-cite"><a href="#ref16">16</a></span> Using the NPI, the following 10 symptoms were rated on the basis of the patients’ condition during the month before the interview: delusions, hallucinations, agitation, depression, anxiety, euphoria, apathy, disinhibition, irritability, and aberrant motor behavior. In the NPI, caregivers are first asked a screening question to determine whether or not the symptom is present. If present, symptom frequency is rated from 1 (&lt;<span class="thinspace"> </span>once per week) to 4 (at least once per day), and severity is rated from 1 (mild, present but not causing distress) to 3 (severe, very disruptive), with a maximum total (frequency<span class="thinspace"> </span>×<span class="thinspace"> </span>severity) score of 12 for each domain. The NPI assessments were performed within a month of the first visit. The NPI total score, total score excluding the hallucinations domain, total score excluding the hallucinations and delusions domain, and the presence or absence of each of the 10 items were assessed. In addition, the presence or absence of the following 8 types of delusional thoughts was assessed using the items from the delusion subdomain of the NPI: delusion of persecution, delusion of theft, delusional jealousy, phantom boarder delusion, Capgras delusion, misidentification of one’s house as another place, delusion of abandonment, and the TV phenomenon.</p> <p class="body-text">We assessed the presence of auditory hallucinations using the items from the hallucinations subdomain of the NPI. Patients who answered “yes” to the question “Does the patient claim he or she can hear voices and sounds or act as if he or she hears voices and sounds?” were assigned to the auditory hallucination group. We excluded patients who only answered “yes” to the auditory hallucination subdomain question “Does he or she talk to people who are not there?” because even patients who experience only visual hallucinations can meet this condition. The remaining patients were assigned to the non–auditory hallucination group. We regarded visual hallucinations as present if patients answered “yes” to the hallucinations subscale question “Does the patient describe seeing things not seen by others or behave as if he/she is seeing things not seen by others (people, animals, lights, etc)?”</p> <p class="body-text">For each patient who experienced hallucinations, we routinely obtained their consent from the primary caregiver using the NPI, and senior neuropsychiatrists routinely questioned each patient about the details of their hallucinations. One of the authors (N.T.) reviewed all available clinical records of patients with auditory and/or visual hallucinations to investigate their clinical features.</p> <p class="subheads-subhead-2">Statistical Analysis</p> <p class="body-text">Student <span class="italic">t</span> tests or χ<span class="superscript">2</span> tests were used to compare the auditory hallucination group and the non–auditory hallucination group in terms of their demographic and clinical characteristics, total NPI score, total NPI score excluding the hallucinations domain, total NPI score excluding the hallucinations and delusions domain, the frequency of individual NPI domains, and the frequency of each type of delusion. Multiple logistic regression analysis was performed to identify significant independent predictors of auditory hallucinations. The following variables were entered: age, sex, duration of education, MMSE score, presence or absence of hearing impairment, use of cholinesterase inhibitors, antiparkinsonian and antipsychotic drugs, and total NPI scores excluding the hallucinations domain. Multiple regression analysis was used to test the association between auditory hallucinations and other neuropsychiatric symptoms. The significance level was set at <span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.05, 2-tailed, for all analyses. Statistical operations were performed with SPSS for Windows, version 21 (IBM Japan, Tokyo, Japan).</p> <p class="subheads_subhead-1-left"><span class="bold">RESULTS</span></p> <p class="body-text">Of the 124 patients, 79 (63.7%) reported having experienced hallucinations within the previous month; of these, 44 (35.5%) had auditory hallucinations, 75 (60.5%) had visual hallucinations, and 40 (32.3%) had auditory plus visual hallucinations. The majority of patients with auditory hallucinations also had visual hallucinations (90.9%), whereas only 4 patients reported auditory hallucinations unaccompanied by visual hallucinations. <span class="callout"><a href="#" onclick="createFigure('f1'); return false;">Figure 1</a></span> shows the overlap between auditory hallucinations and visual hallucinations.</p>

<p class="body-text">The contents of auditory hallucinations consisted mostly of human voices (41 patients), the sound of running water (1 patient), and unspecified sounds (2 patients). There were close phenomenological relationships between auditory and visual hallucinations. Of the 41 patients with verbal auditory hallucinations, 37 patients (90%) heard the visual hallucinations speak. In 25 patients (61%), the visual hallucinations spoke to them, and 4 patients reported that the voices gave commands such as “Get up early.” With respect to the subjective affective aspects of auditory hallucinations, 29 (71%) patients whose auditory hallucinations consisted of voices experienced bad or unpleasant voices. For example, some patients reported that they heard several people speak ill of them, and others reported that they heard someone discussing plans to frame them. Only 4 patients (10%) reported good or pleasant voices telling them, for instance, that they intended to prepare tea and food for imaginary guests. The rest reported neither good nor bad voices.</p> <p class="body-text">The frequencies of the individual NPI domains and of each delusional thought in the 2 groups are shown in <span class="callout"><a href="#" onclick="createFigure('t3'); return false;">Table 3</a></span>. Three of the NPI individual domains were associated with the presence of auditory hallucinations: higher frequencies of delusions, depression, and aberrant motor behavior. The frequencies of delusions of persecution, delusions of theft, phantom boarder delusions, and the TV phenomenon were significantly higher in the auditory hallucination than in the non–auditory hallucination group. Multiple regression analysis revealed that the presence of visual hallucinations (<span class="italic">P</span><span class="thinspace"> </span>&lt;<span class="thinspace"> </span>.001), phantom boarder delusions (<span class="italic">P</span><span class="thinspace"> </span>=<span class="thinspace"> </span>.001), and depression (<span class="italic">P</span><span class="thinspace"> </span>=<span class="thinspace"> </span>.038) was independently correlated with the presence of auditory hallucinations.</p>